| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | REPEAT-62a The double cabinet in the kitchen near the exit to the kitchen which contains poisons, including cleaning supplies, was unlocked. The lock attached was broken. Individual #1's current ISP 9/22/2021 states all poisonous materials must be locked. Individual #1's personal care/grooming products were unlocked in the bathroom cabinet. | Poisonous materials shall be kept locked or made inaccessible to individuals. | House Managers and DSPs are responsible for assuring that all poisonous materials are kept safely away from individuals as required by their ISPs. Residential Supervisors are responsible for checking on this during their weekly visits to assure poisons are always inaccessible to the individuals in the home.
These containers were removed from both the bathroom and the kitchen cabinet on 10/5/21 and moved to the basement and locked.
The existence of unlocked chemical bottles was checked in remaining homes across the region on 10/6/21 and any that were unlocked, regardless of ISP stipulations were locked, but staff were retrained across the region.
House staff and management staff were trained on this requirement again on 10/12/2020. |
10/05/2021
| Implemented |
| 6400.64(a) | The front door porch light was three-quarters fills with dead flies and bugs. | Clean and sanitary conditions shall be maintained in the home. | The maintenance crew cleaned mentioned areas the evening of inspection on 10/23/21 to meet expected standards.
House Managers and DSPs are responsible for assuring the cleanliness of each residence. There is a daily/weekly cleaning list in each home to be followed by staff. The House Manager bears the front-line responsibility to make sure it is initialed off and followed by each shift.
The Residential Supervisor is responsible for checking on this during their weekly visits to assure facility remains clean and safe.
The Regional Director is responsible to inspect facility for cleanliness on a weekly basis. |
10/23/2021
| Implemented |
| 6400.67(a) | The three drawer filing cabinet in the kitchen/staff area is broken. The second drawer does not shut; it remains opens approximately 2 and a half inches. The bottom drawer does not open. The third story bathroom sink has a large triangular shaped broken off/missing piece on the right side, approximately one foot in length. | Floors, walls, ceilings and other surfaces shall be in good repair. | House Managers are responsible for informing the Residential Supervisor of any maintenance items as they occur. Updated maintenance concerns are to be reported daily by EOPs on the proper maintenance form located on Extended Reach, our current Electronic Management System.
Residential Supervisors are to verify that items are entered in our electronic maintenance request system and inform Regional Director within 24 hours.
The Regional Director keeps a running list of all outstanding maintenance items to discuss with maintenance and have resolved if they linger for more than a week. Maintenance issue are to be addressed in a timely manner. This item replaced with a locking cabinet on 10/8/21.
All outstanding items were addressed with maintenance on 10/16/21 across the region. All staff were retrained on the procedure to file maintenance issue on 10/15/21. |
10/08/2021
| Implemented |
| 6400.74 | REPEAT-74 The two wooden steps leading to the third story door of the home did not have a non-skid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Regional Director provided non-skid material for steps on 10/14/21, and House Manager put it on two steps needing it and sent pictures to Director for verification.
The House Manager will be responsible for checking that non skid is on all needed surfaces and in good repair each week.
The Residential Supervisor and Regional Director will be responsible for assuring this is done on all interior and exterior steps during their weekly visits.
All homes were inspected for the need of non-skid strips the week of 10/11/21 and those homes requiring any repair were provided the material to do so by the Regional Director. |
10/14/2021
| Implemented |
| 6400.77(b) | First Aid Kit did not contain tape. This first aid kit was also broken and could not shut. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The House Manager is responsible for needed items being inside the first aid kits in each home. They are responsible to check these for use of contents and replenish. The Manager should also check for condition of the kit in general.
The House Manager will notify the Residential Supervisor if they are in need of restocking the First Aid Kit or replacing any that are broken or in disrepair for any reason.
The Residential Supervisor is responsible to make sure needed items reported missing or entire kits are replaced when items are reported from the House Manager as needing replaced.
This First Aid Kit was totally replaced by Director on 10/14/20. |
10/14/2021
| Implemented |
| 6400.103 | The emergency evacuation procedures for the home does not include the individual and staff responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Regional Director has updated the evacuation plans across the region to reflect missing information regarding individual and staff responsibilities on 10/6/21.
Evacuation procedures will be reviewed for all homes in the region each January to incorporate any needed changes.
Regional Director will review and approve all evacuation plans if needed changes arise for any home in the region. |
10/06/2021
| Implemented |
| 6400.144 | Individual #1's medication Alphabath Oil use 2 drops in each ear at bedtime once a week was signed by staff as given October 1st-4th, 2021 at 8PM. Original order was written 7/29/2019. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| All EOPS and House Managers must take the state Medication Administration training which consists of online modules with quizzes to pass, a face-to-face segment for a documentation and multiple choice test, and two onsite observations before being able to independently administer medication.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company.
Staff signing off on this medication, while not actually given, were retrained by Medication Trainer on 10/6/21 and log was updated to show actual administration of this medication. |
10/06/2021
| Implemented |
| 6400.216(a) | There was a note in the staff office area hanging on the bulletin board that read individual #1's bowel movement protocol and instructions for staff to log his weight every Sunday. Individual #2's copy of her September 2021 and October 2021 medication administration records were in manila folders on the kitchen table. On a tall table/shelf near the kitchen window unlocked records included: Bowel movement charts August and September 2021 for individual #1; binder containing individual #2 and individual #1's consumer petty cash logs for September 2021; a note to staff that individual #1 does not require to wear his safety helmet inside his home; a copy of individual #2 and individual #1's ISP and protocols. In the drawers on the tall table/shelf in the kitchen there were other unlocked records that included: individual individual #2 and individual #1s letters to the fire company dated 6/28/2020; individual #1's 10/1/2020 individual Assessment; Individual #1's September 2019 medication administration records; individual #1's November 2019 Quarterly Review; individual #1's note dated November 20. 2019 from HOPE Innovations; Individual #1's March 11, 2020 individual Assessment addendum letter; a composition notebook containing staff notes regarding individual #2 and individual #1 and also past residents who lived at the home. | An individual's records shall be kept locked when unattended.
| House Manager and EOPs at this location were retrained on the need for confidentiality and locked documents on 10/6/21 by the Regional Director.
The House Manager and all EOPs are responsible to ensure all documentation having a name of one of the individuals is under lock and key unless being used directly by staff.
The Residential Supervisor and Regional Director are responsible to ensure confidentiality during weekly visits to the home. |
10/06/2021
| Implemented |
| 6400.163(a) | Individual #1's medication Alphabath Oil use 2 drops in each ear at bedtime once a week pharmacy label was illegible. It was rubbed off from use and also the fact that it is an oily medication. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | House Manager ordered a new prescription of the Alphabath Oil to have a new, clear label on it. The new label will be covered with plastic to protect the label from fading due to oil penetration.
House Manager and EOPs are responsible to keep medications in good order so that labels can be compared to MAR as per Medication Administration Training passed by all employees of Spectrum. Each staff will check labels at each administration for any issues and report to the House Manager. |
10/25/2021
| Implemented |
| 6400.163(h) | In the first aid kit, a Physicians Care purified water 98.3% ophthalmic solution eyewash, expired June 2021. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The expired eye wash was disposed of during the inspection on 10/5/21.
House Managers and EOPs are responsible to check contents of the First Aid Kit on a regular basis and replace any needed materials and make sure all required items are present.
The House Manager is responsible to replace any needed materials or replace entire First Aid Kit if the kit is in disrepair.
The Residential Supervisor is responsible to check the status of all aspects of the First Aid Kit upon weekly site visits. |
10/05/2021
| Implemented |
| 6400.165(c) | Individual #1 medications should be crushed before ingesting them. Not all his medications are noted to be crushed on his October 2021 medication administration record, as per doctor's order. This includes Tegretol 200mg take 3 tablets (600mg) by mouth in the evening and Benztropine 1mg take 1 tablet by mouth at bedtime. Individual #1 medication Alphabath Oil use 2 drops in each ear at bedtime once a week was signed by staff as given October 1st-4th, 2021 at 8PM. Original order was written 7/29/2019. | A prescription medication shall be administered as prescribed. | Medication labels were sent to corporate office and reentered on the MAR to match the prescription labels on 10/6/21. Staff were retrained on all errors listed, some addressed in a separate citation in more detail, 10/06/21.
All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/06/2021
| Implemented |
| 6400.166(a)(8) | Individual #1's medications should be crushed before ingesting them. Not all his medications are noted to be crushed on his October 2021 medication administration record, as per doctor's order. This includes Tegretol 200mg take 3 tablets (600mg) by mouth in the evening and Benztropine 1mg take 1 tablet by mouth at bedtime. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Medication labels were sent to corporate office and reentered on the MAR to match the prescription labels on 10/6/21. Staff were retrained on 10/06/21.
All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/06/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's October 2021 medication administration records do not include the reason for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | House Manager called the PCP and Pharmacy to have reason for a medication added to every script for the individual. All medications have reasons provided by the doctor and new labels sent 10/25/21. Staff were retrained on 10/08/21 on the need for reasons to be listed on the actual script and the need for pictures to be sent to the corporate office to be added to the MAR permanently.
All EOPS and House Managers are trained and responsible for adding new medications prescribed to the MAR with proper labeling and sending the label information to our corporate contact to be added to the MAR permanently until discontinued so the MAR will show correct and current medication information including the reason for the medication.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/25/2021
| Implemented |
| 6400.167(a)(3) | Individual #1's medication Alphabath Oil use 2 drops in each ear at bedtime once a week was signed by staff as given October 1st-4th, 2021 at 8PM. | Medication errors include the following: Administration of the wrong dose of medication. | Staff were retrained on 10/06/21 to include proper documentation in the administration box of the MAR.
All EOPS and House Managers are trained and responsible for putting the correct information in the administration box of the MAR for every medication given.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/06/2021
| Implemented |
| 6400.167(c) | A medication error shall be reported as an incident as specified in §6400.18(b) (relating to incident report and investigation). Individual #1s medication Alphabath Oil use 2 drops in each ear at bedtime once a week was signed by staff as given October 1st-4th, 2021 at 8PM. Original order was written 7/29/2019. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | All EOPS and House Managers are trained and responsible for reporting medication errors to either the House Manager or Residential Supervisor to be reported within the HCSIS system.
This incident was entered into the HCSIS system on 10/6/21 by the Regional Director as a result of the inspection on 10/5/21.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home including the reporting of reportable incidents to management.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/06/2021
| Implemented |
| 6400.167(d)(1) | A medication error shall be reported to the prescriber under any of the following conditions: 1. (Administering the medication) other than as directed by the prescriber. Individual #1's medication Alphabath Oil use 2 drops in each ear at bedtime once a week was signed by staff as given October 1st-4th, 2021 at 8PM. Original order was written 7/29/2019. | A medication error shall be reported to the prescriber under any of the following conditions: As directed by the prescriber. | Staff were retrained on 10/06/21 to include proper documentation in the administration box of the MAR. The medication was given as directed, but it was not documented correctly.
All EOPS and House Managers are trained and responsible for putting the correct information in the administration box of the MAR for every medication given.
The Residential Supervisor has final sign off on shadowing and preparedness of staff to work in the home.
All staff, regardless of position, are required to be undergo Medication Administration Training before working in the home alone during a medication administration time.
All staff are trained by a licensed Medication Administration Trainer within the company, including two onsite observations, before administering any medication to individuals. |
10/06/2021
| Implemented |